Psychiatric Care For Ill Homeless May Be Lengthy

By JOSH BARBANEL

Published: December 7, 1987

When New York City officials began to hospitalize mentally ill street people against their will, they believed that they would be able to move many of the patients out of the wards and into the community.

But five weeks later, with many of the homeless people showing little if any improvement, city psychiatrists say the patients are typically far sicker than had been expected and far more likely to require long-term treatment in state hospitals. If it continues, city officials say, this pattern would raise new questions about whether enough psychiatric beds are available in an already overcrowded mental-health system.

''A higher percentage of these patients will need extended care in state units,'' said Dr. Sara L. Kellerman, the city's Commissioner of Mental Health. ''It's hard to make the math work any other way.'' 'Lock and Key'

Since Mayor Koch's program began, public attention has been centered on the legal battles of Joyce Brown, the first person picked up, to win her release from the hospital. Miss Brown, who appears articulate and lucid in court, has raised questions about whether the program is designed to help deeply disturbed people or clean up affluent neighborhoods.

''The choice cannot be living on the streets or living under lock and key at Bellevue,'' said Norman Siegel, executive director of the New York Civil Liberties Union, which has represented Joyce Brown in court. ''In sweeping up the homeless, the Mayor is attempting to place these people out of sight and out of mind and hide the crisis from public consciousness.''

But doctors at Bellevue say Joyce Brown's case is far from typical. Behind the locked yellow doors of 18 West, the Bellevue ward, these psychiatrists say, they face a day-by-day struggle to break through the deep social isolation of their patients.

Despite some notable successes - a 38-year-old former elementary school teacher was discharged after being reunited with a brother who had been searching for him for years - doctors say many patients have only modest responses to medication and continue to live in a world of painful isolation.

''We are talking about treatment, not cure of people who will not fully function in society,'' said Dr. David Nardacci, the 32-year-old psychiatrist who runs the unit.

Since the program began, teams of city workers from Project Help with little fanfare have evaluated 98 people on the streets, and taken 38 to Bellevue, at First Avenue and 28th Street in Manhattan, for treatment. One man, an alcoholic with a leg infection and said to be suffering from depression, was brought in twice. 'Terribly Isolated Lives'

Far more than in other psychiatric wards at Bellevue - where patients, including other homeless people, are brought in by the police after some aggressive act - the patients on 18 West, a 28-bed ward, are passive, withdrawn and regressed, Dr. Nardacci said.

They shuffle down the ward's main corridor, much as they shuffled down city streets. Many move alone in slow motion as a side effect of anti-psychotic medication they have taken, making little contact with the staff or other patients.

''They lead terribly isolated lives,'' Dr. Nardacci said. ''Their illness involves ongoing hallucinations, and the patients are lost in their own worlds. They are isolated from family and friends.''

Though staff members run therapy sessions of yoga, bingo, art and music therapy to bring people together, many patients mix with other patients only to borrow cigarettes or to change the channel on the television, he said. When they watch television in the same room, they sit apart. White and Middle-Class

According to data provided by the city, these severely mentally ill patients differ significantly from the typically poor and black and Hispanic residents of the city shelter system. They are much more likely to be white and from middle-class backgrounds, and from other parts of the country.

Dr. Nardacci, said that, despite the dispute over Joyce Brown, his patients represent the most severely disabled people, among a larger group of mentally ill homeless people, and a still larger group of homeless people.

''We are not bringing in functioning people whose primary diagnosis is a social breakdown, or an economic problem,'' he said.

Of those picked up, 63 percent were white, 21 percent black, 13 percent people of Hispanic origin, and 1 percent Asian (a single Vietnamese woman picked up at the Staten Island Ferry Terminal). A little more than half were male. Almost half were picked up at transportation hubs. Serious Medical Problems

About half were found to have a potentially serious medical problem, ranging from two women with lumps in a breast, one patient with venereal disease, four with positive tuberculosis tests, to many patients with ulcers, skin conditions and other infections. Many were found to be underweight. Most had lice. The main psychiatric diagnosis was chronic schizophrenia, undifferentiated type, a disorder of thought and feeling, in which people increasingly lose touch with reality. Psychiatrists say that traditionally these passive patients are less likely to respond to anti-psychotic drugs than patients with acute symptoms.

When the city first announced its plan to involuntarily hospitalize mentally ill street people, advocates for the homeless contended that the already overcrowded mental health system, in which city psychiatric wards were routinely filled to capacity, would not be able to cope with the influx of patients.

The city said that to meet the demand, it would open a special ward where patients would stay an average of 21 days. After that, about 35 percent of all patients were to be transferred to state hospitals, 35 percent to community residences for the mentally ill, and the balance to nursing homes, adult homes, or medical wards. Longer Stays Seen

But Dr. Luis Marcos, the vice president for mental hygiene of the city's hospital system, said that after five weeks of experience, city officials are beginning to wonder whether that schedule is realistic.

Even though the program is only five weeks old, the average lengthtof ftay has already slipped to 24 days a patient. And in cases where the city has developed a tentative discharge plan, two-thirds were scheduled to go to state hospitals.

''We are finding that the medical and psychiatric needs of these patients are great,'' Dr. Marcos said. ''That, coupled with the legal hassles, means that they may have to stay longer at Bellevue.''

So far, he said, only seven patients have left Bellevue. Six were transferred to a 50-bed unit at the Creedmoor state psychiatric center that the state has set aside for the program, the seventh, the cartoonist, was released to his family in Queens. Plan Is Criticized

Three patients are on medical wards, 27 are on the homeless ward, and one was placed on another psychiatric ward when beds in the special ward were filled. Dr. Marcos said that if the current trend continues, the state might have to provide many more long-term beds.

Opponents of the plan have argued that the plan is a misguided effort to push more and more patients back into state psychiatric hospitals, because of the failure to provide housing for the homeless and community residences for the mentally ill.

Ilene D. Margolin, a deputy secretary to Governor Cuomo, said that it was not yet possible to project the need for state hospital beds based on the small number of patients in the city's program to date.

She said that the state was now trying to develop new types of care for mentally ill people that are less restrictive than vast state hospitals, and more structured than existing community alternatives. Charge of Cynicism

But, she added, ''If there are people who need treatment in state hospitals we are not going to turn our back on them.''

If more state hospital beds are needed, it would represent a reversal of the policy of deinstitutionalization, a concern for the rights of patients that led to a sweeping reduction in the number of state psychiatric patients in New York, from 93,000 in 1955 to about 20,000 today, and contributed to the surge in the numbers of homeless mentally ill.

Critics of the plan, especially Mr. Siegel, have also suggested that the program has been cynically targeted at the business district, and ''mainly white affluent neighborhoods'' in Manhattan.

''If they were really concerned about homeless people why do they have this program primarily targeted at those areas,'' he said.

A survey of the first 35 patients showed that 16 were picked up at major transportation terminals, six on downtown streets, five in midtown, five on the East Side, one on the West Side, and two in Central Park.

Dr. Kellermann, the city's Mental Health Commissioner, confirmed that until Mr. Siegel's complaint, the program had been limited to areas below 110th Street on the West Side and below 96th Street on the East Side in Manhattan.

She said this was done because her department believed that the mentally ill homeless were concentrated mainly in the lower half of Manhattan and in downtown Brooklyn. Each month, she said, outreach teams contact 1,400 homeless people in these areas, and regularly track between 300 and 400 mentally ill homeless people.

After Mr. Siegel complained, she said, outreach teams were dispatched to conduct surveys of mentally ill homeless people in upper Manhattan, and have so far identified a small number of people who might need help. She said the outreach teams would continue periodic visits.

Joyce Brown is now awaiting a ruling by the appellate division of State Supreme Court in Manhattan, possibly as early as Tuesday, in a case that could set limits on the grounds that the city can use in involuntarily hospitalizing mentally ill homeless people.

In 11 other challenges to the city's decision on patient care, the city lost only once. A state supreme court justice barred the city from transferring a Vietnamese woman to a state psychiatric hospital, and told the city to place her in a group home instead. The city is appealing.

But Dr. Nardacci and other city psychiatrists say that they are more concerned with helping people than the intricate details of the commitment law, suggesting that legal conflicts may continue into the future.

This became evident when an alcoholic man believed to be suffering from severe depression, as well as a leg infection, was picked up last November 15th.

The man told doctors that he was grateful that they brought him in. He was made a voluntary patient at the hospital. Once he sobered up, it became apparent that alcoholism was the cause of the depression, city officials said.

Though the man agreed to enter an alcoholism treatment program he did not show up - a common pattern among alcoholics. City workers who kept track of him on the street saw his condition deteriorate again, and brought him back to the hospital, once again arguing that he was mentally ill and a danger to himself.

Asked about the case, Dr. Nardacci said that doctors were continuing to explore the man's mental state, and added that he had chosen to be a doctor, not a lawyer. ''Sometimes something like Project Help has to come along,'' he said.

Dr. Nardacci said that young and dedicated staff members on the ward remain enthusiastic, despite the difficulties and frustrations they face.

In one case, a 45-year-old woman was brought in on November 11th, after she caused a disturbance at a soup kitchen On admission she said he was active politically and associated with Patty Hearst.

The woman, a former receptionist, was diagnosed as having a bipolar disorder, characterized by severe mood swings, and she quickly responded to medication. She will soon be reunited with relatives from Buffalo, city officials said.

In another case, Dr. Nardacci said success is measured by the willingness of a patient to consider that the hospital might have some advantages over living on the street.

''Right now he sees the pros and cons of living in the hospital,'' Dr. Nardacci said. ''Previously he saw only the cons.'' Off the Streets Aganinst Their Will: Sketches of 7 Treated at Bellevue Patient description: Joyce Brown A 40-year-old former secretary picked up Oct. 28 in front of a hot-air vent on Second Avenue at 65th Street. Defecated, urinated in street, tore up or burned paper money. State judge found that city had failed to prove that she is mentally ill or a danger to herself. City's diagnosis: Chronic schizophrenia, paranoid type, according to city. Her lawyers say she is not mentally ill. Outlook: Tests are under way to determine if she is suffering from a genetic ailment that may affect the brain.

Miss Brown once described herself as a ''professional street person.''

Now says she wants to get a job and apartment. If city wins appeal, it may seek court order for forced medication. Patient description: Unidentified 38-year-old man Picked up on a midtown sidewalk Oct. 28, covered with lice and smelling of feces. College graduate, former elementary school teacher who worked as a cartoonist four years ago. City's diagnosis: Schizophrenia, undifferentiated type. Outlook: Showed slight improvement in hospital. With help of neighborhood friend, social workers found a brother in Queens who had been looking for him.

Discharged from hospital to family on Thanksgiving Day. Enrolling in outpatient program. Patient description: Sharon Zak A 37-year-old blind woman picked up Oct. 29 on Broadway near 109th Street.

Seeing-eye dog taken away because she abused it. Refused help on the street. Receives Social Security and says she lives in YWCA and church shelter until her money runs out. Judge rejected petition for release. City's diagnosis: Schizophrenia, atypical psychosis. Outlook: Refused medication until city moved to get court order.

According to records, is still disorganized and ''walks up and down hallway talking to self, sometimes cursing.'' Doctors waiting to see if medication helps. Patient description: Helen Phillips A 64-year-old woman who lived in Pennsylvania Station for four years, and before that in the subways. Picked up Oct. 30. Has delusions that she will be killed and has plutonium in her body. Turned down for release. City's diagnosis: Schizophrenia, paranoid type. Outlook: Cooperative, pleasant with staff, but has little interaction with others.

Staff contacted family but they are unwilling or unable to accept responsibility for patient. She expressed interest in St. Francis Residence, model residence for former patients. Staff exploring possibility. Patient description: GiaM Long A 41-year-old Vietnamese woman. Thin, pale, friendly. Picked up at Staten Island Ferry Terminal Nov. 3 after losing weight and increasingly bizarre behavior. Came to United State in 1972, and has been repeatedly hospitalized since. Ritualistic hand-washing has caused skin breakdown. Says food in restaurants is poisoned. City's diagnosis: Schizophrenia, paranoid type, mild anemia, skin lesions. Outlook: Moderately agitated, she is grossly disorganized and unable to follow most directions. Friend in Hong Kong, with whom she lived 10 years ago, knew of no family.

Judge blocked city efforts to transfer her to Creedmoor Psychiatric Center and told the city to find a community residence instead. City has appealed. Patient description: 45-year-old woman Former receptionist, recently released from another hospital. Threw cigarettes and verbally abused other homeless people and staff at lunch program. Very agitated and hostile when approached. ''Patient is delusional claiming she was with Patty Hearst and that she is a political activist,'' according to records. Picked up Nov. 11. City's diagnosis: Bi-polar disorder, manic phase. Outlook: Soon after arrival, patient banged head against a window to get staff attention. Continues to improve, but still ''somewhat socially abrasive and grandiose.'' Social workers say her family in Buffalo agrees to take her home. Patient description: 25-year-old man Tall slender long-haired, picked up at Grand Central Terminal Oct. 29. Socially isolated, muttering and talking to himself, caked with dirt. Weight loss. Inappropriate clothing. Lice. City's diagnosis: Schizophrenia, disorganized type. Outlook: Patient does not interact with peers, seems autistic and is often seen shadow boxing. Requested court hearing on city request to move him to Creedmoor, but then changed his mind. Transferred Nov. 28. Sources: New York City Health and Hospitals Corporation and city officials.